TATALAKSANA MEDIK PADA PASIEN STROKE

dr. Ita Muharram Sari, Sp.S

Divisi Neuroemergensi & Neurointensif
Ketua Tim Stroke
RS Pusat Otak Nasional
MANAJEMEN STROKE AKUT

Empat hal utama dalam penatalaksanaan stroke akut di rumah sakit:

1. Penanganan kondisi fisiologi pasien.
2. Terapi spesifik yang berhubungan langsung dengan berbagai
patogenesis stroke. (rekanalisasi, neuroproteksi)
3. Profilaksis dan penanganan komplikasi.
4. Rehabilitasi secepatnya.

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Guideline Stroke Perdossi, 2011 2

PENANGANAN STROKE PRA HOSPITAL

• Deteksi Dini 95% kasus di luar RS

• Pengiriman Pasien (ambulans /transportasi udara)
• Fasilitas ideal ambulans : personel terlatih, peralatan & obat
resusitasi, mesin EKG, glucometer, pulse oximeter

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Guideline Stroke Perdossi, 2011

PENANGANAN STROKE PRA HOSPITAL
• Beberapa hal yg harus diperhatikan petugas pelayanan ambulans :
• Jangan terlambat membawa ke RS yang tepat
• Jangan memberikan cairan berlebihan kecuali pada pasien syok &
hipotensi
• Hindari pemberian cairan glukosa/dekstrose, kecuali hipoglikemia
• Hindari hipotensi, hipoventilasi
• Catat waktu onset serangan
• Memanfaatkan jaringan pelayanan stroke komprehensif, yaitu IGD, stroke
unit atau ICU sebagai tujuan penanganan definitif pasien stroke
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Guideline Stroke Perdossi, 2011

 PENATALAKSANAAN UMUM STROKE AKUT

• Stabilisasi jalan nafas & Pernafasan  Tx O2 pada pasien hipoksia (SaO2 < 95%)
• Stabilisasi hemodinamik  cairan kristaloid, CVC, optimalisasi tekanan darah
• Pengendalian Peninggian Tekanan Intra Kranial
• Pengendalian Kejang, Suhu Tubuh, kadar glukosa darah
• Nutrisi enteral 1x24 jam, evaluasi disfagia
• Pencegahan & Penanganan Komplikasi  aspirasi, malnutrisi, DVT, emboli paru,
dekubitus

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Guideline Stroke Perdossi, 2011

 TIME is BRAIN

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• Brain = 2 % BB, O2 demand 20% CO
• Average neurons in human forebrain :
22 billion
• Ischemic stroke : 1.9 million neurons,
14 billion synapses & 12 km (7.5
miles) of myelinated fibers are
destroyed /minute

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Ischemic Stroke
7/29/2019 7
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 PENATALAKSANAAN KHUSUS STROKE ISKEMIK

• 0-4.5 hours
Trombolisis iv rtPA (alteplase)
• 0-24 hours
Endovascular treatment (in addition to iv tPA)
(Mechanical Thrombectomy)

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Powers WJ, 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the AHA/ASA, Stroke
2018 ; 49: e46-e99
TROMBOLISIS

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 RTPA IN NBC
Number of stroke patients in NBC
Admision patients from ER
3000
500

400 2500 2432

300 2000 1963

2018 (N=4755)
200 1681 Ischemic Stroke
2017 (N=3614) 1500
1387 ICH stroke
100 2016 (N=3194) 1250 Total stroke patients
1000 1022
0
500
n
b

ly

g
r
ay

c
v
v
ne

pt
ch

469
Ap

De
No
No
Au

431
Fe
Ja

Ju

Se
M
ar

365
Ju

rTPA
M

10 20 123
0
2016 2017 2018

2016 2017 2018

1 : 102 1 : 62.5 1:16
0.98 % 1,6% 6,27 %

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PENATALAKSANAAN KHUSUS STROKE PIS

Resiko : rebleeding, ongoing bleeding

Manajemen penanganan peningkatan tekanan
intrakranial

Konsultasi Bedah Saraf hidrosefalus,

evakuasi hematoma, dekompresi
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PENATALAKSANAAN KHUSUS STROKE PSA

• Caution : Thunderclap headache

• Evaluasi klinis : Grading Hunt & Hess
• Diagnosa : CT Angiografi
• Penanganan vasospasme cerebral triple H
(hypervolemic-hypertensive-hemodilution),
nimodipin
• Aneurisma : endovascular coiling / surgical
clipping
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ALGORITHM TREATMENT
ACUTE HYPERTENSIVE
RESPONSE
For ICH patients presenting with
SBP between 150 and 220
mmHg and without
contraindication to acute BP
treatment, acute lowering of
SBP to 140 mmHg is safe (Class
I; LoE A) and can be effective for
improving functional outcome
Qureshi AI, Acute Hypertensive Response in (Class IIa; LoE B)
Patients with Stroke, Circulation 2008;118:176-187 no other end-organ damage, such as:

Powers WJ, 2018 Guidelines for the Early Management of Patients

15% ---during first 24
cardiac ischemia
acute heart failure
With Acute Ischemic Stroke: A Guideline for Healthcare hours onset
-- aortic stroke
dissection
- acute renal failure
Professionals From the AHA/ASA, Stroke 2018 ; 49: e46-e99
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Hemphilllll JC, Guidelines for the Management of
Spontaneous ICH , Stroke 2015;46;2032-2060
 ACUTE ISCHEMIC STROKE WITH TROMBOLYSIS

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Powers WJ, 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the AHA/ASA,
Stroke 2018 ; 49: e46-e99
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